Anesthesiology ,Critical Care, Pain management

Background: The effect of biphasic positive airway pressure (BPAP) at individualized pressures on the postoperative pulmonary recovery of morbidly obese patients (MOP) undergoing open bariatric surgery (OBS) and possible placebo device-related effects (sham BPAP) were investigated.
Methods: Forty-eight MOP scheduled for OBS were initially enrolled. Subjects were randomly assigned to: A) the BPAP group in which BPAP, at individualized inspiratory positive airway pressure/expiratory positive airway pressure (IPAP/EPAP), was applied for 3 days postoperatively and B) the sham BPAP group in which sham BPAP was applied for the same time. Pulmonary function was assessed by spirometry 24 h prior to surgery and at 24, 48 and 72 h postoperatively and respiratory complications were recorded.
Results: Thirty-five subjects, 21 in the BPAP group and 14 in the sham BPAP group, completed the study. Baseline characteristics and pulmonary function were similar between groups preoperatively. Subjects in the BPAP group showed in general better spirometric performance and SpO2 values postoperatively and expedited pulmonary recovery. Atelectasis combined with respiratory distress syndrome (RDS) symptoms was observed in 21% of subjects in the sham BPAP group and one of these subjects developed lower respiratory tract infection. No respiratory complications were recorded in the BPAP group. Use of higher BPAP pressures was not associated with anastomosis leakage or disruption in any patient.
Conclusion: Use of BPAP, at individualized pressures, expedites postoperative pulmonary recovery and eliminates respiratory complications in MOP who have undergone OBS.

Introduction: Postponed recuperation from anesthesia can lead to different complications such as apnoea, aspiration of gastric content whit consequent development of aspiration pneumonia, laryngospasm, bradycardia, and hypoxia. Aim of this research was to determine infl uence of propofol, sevoflurane and isoflurane anesthesia on post anesthesia recovery rate.
Methods: This was a prospective study; it included 90 patients hospitalized in period form October 2011 to may 2012 year, all patients included in the study underwent lumbar microdiscectomy surgery. Patients were randomly allocated to one of three groups: group 1: propofol maintained anesthesia, group 2: sevoflurane and group 3: isofl urane maintained anesthesia. Assessments of recovery rate were done 1, 5 and 10 minutes post extubation using White fast tracking scoring system.
Results: Significant difference was observed only 1 minute after extubation (p=0,025) finding recovery rate to be superior in propofol group. Propofol group compared to inhaled anesthesia with sevoflurane group, shows significantly faster recovery from anesthesia only one minute after extubation (p=0,046). In comparison of propofol group and isofl urane anesthesia group, statistical significance was noticed one minute following extubation (p=0,008). Comparison of propofol group and inhaled anesthesia groups recovery rates were not significantly different at all times measured. When we were comparing sevoflurane and isoflurane anesthesia, recovery rates shoved no signifi cant statistical difference.
Conclusions: Recovery rate evaluated by using White fast tracking scoring system was superior and with fewer complications in propofol maintained in comparison to sevoflurane and isoflurane maintained anesthesia only one minute post extubation, while after fifth and tenth minute difference was lost.

Le bloc ilio-fascial est une technique d’analgésie de référence ayant montrée son intérêt et son innocuité en urgence préhospitalière. Les indications du bloc ilio-fascial sont les fractures de la diaphyse fémorale mais aussi les lésions touchant les structures osseuses de la hanche. Les contre-indications sont nombreuses en traumatologie préhospitalière et doivent être scrupuleusement respectées. Le geste technique est réalisé après information du patient. Cette anesthésie locorégionale nécessite peu de matériel et consiste en l'injection d’un anesthésique local dans l'espace ilio-fascial où transitent les nerfs fémoral, cutané latéral de la cuisse et obturateur. Le mécanisme de cette analgésie est double : direct par bloc sensitif et indirect par relâchement musculaire. Comme pour toute anesthésie locorégionale les conditions de sécurité élémentaires sont requises avec à disposition immédiate les moyens nécessaires pour palier effets indésirables et complications immédiates (malaise, toxicité systémique, allergie). Nous présentons la technique du bloc ilio-fascial en urgence préhospitalière.

Ketamine has been rarely described for use in critically ill patients. We describe our institutional experience using continuous infusion ketamine for sedation. This was a retrospective chart review of patients admitted to the medical intensive care units (MICUs). An informatics query of patients who received continuous infusion ketamine between 1/1/2010 and 7/1/2012 was conducted. Mechanically ventilated patients in the MICU who received continuous infusion ketamine were included. Twelve patients met criteria. Mean age was 41; 60% were Caucasian and 60% were female. Six patients were admitted for pneumonia, three for asthma exacerbation. Median duration of ketamine therapy was 1.57 days. Median minimum and maximum rates were 0.24mg/kg/hr and 0.83mg/kg/hr. The maximum documented dose used was 2.8mg/kg/hr. The ketamine infusion was discontinued secondary to tachycardia or hypertension in two patients. No patient who received concomitant benzodiazepines experienced hemodynamic changes prompting ketamine cessation. Median maximum SBP, DBP, and HR while on ketamine were 154, 96 and 121, respectively. No further adverse events were identified. Five of the patients had decreases in concomitant sedative and analgesic doses while five had increases. Continuous infusion ketamine can safely be used for adjunctive sedation/analgesia in mechanically ventilated MICU patients. Larger trials are needed to further define optimal dosing and confirm safety.

Wolff-Parkinson-White (WPW) syndrome is a cardiac disorder having abnormal electrical communication between atria and ventricles. It is an uncommon disorder may be asymptomatic or present with symptoms like palpitation. Intraoperatively these patients may present with serious cardiac emergencies like paroxysmal supraventricular tachyarrythmias (PSVT) and atrial fibrillation (AF). We report a case of 35 years old female posted for elective laparoscopic cholecystectomy under general anesthesia with the use of dexmedetomidine in the perioperative period. Perioperative management of these patients under general anesthesia is a real challenge for the anesthesiologists particularly under general anesthesia.

Introduction: The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care
Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs
without an IMCU.
Methods: An observational multinational cohort study performed on patients admitted to participating ICUs during
a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a
day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of
hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital
mortality until hospital discharge (censored at 90 days).
Results: One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113
(19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity
was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for
patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at
admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI
0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients
who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630)
but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002).
Conclusions: The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital
mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment.

Acute pulmonary edema during pregnancy is very rare and occurs in 0.08% pregnancies. About 3% of severe preeclamptic patients develop acute pulmonary edema. Among them 30% develop it in the antenatal period with 90% having pre existing chronic hypertension and 70% develop it in the postnatal period. Several risk factors have been identified: preeclampsia or eclampsia, use of tocolytic therapy, severe infection, cardiac disease, iatrogenic fluid overload, and multiple gestations. No matter what the underlying pathology, resuscitation is the foremost priority. Only after the patient has been stabilized, attention can be turned to the formulation of a differential diagnosis to address the underlying condition and initiate specific treatment. This case examines one such presentation and reviews some of the diagnostic possibilities.

Pectoralis minor blocks are still relatively new and require further evaluation, but may have a place in peri-operative pain management for the appropriate cases. Still considered as less invasive procedure in comparison to thoracic epidurals and para-vertebral blocks. Complications of thoracic epidural and para-vertebral blocks like spinal cord injury and pneumothorax makes many anaesthetists interested in practising pectoralis minor block guided by ultrasound. Blanco first introduced the pectoralis minor block in 2011, he did study on 50 patients within 2 years. Results were very promising, all patients did not need any opiates but only paracetamol and non-steroidal anti-inflammatory (NSAID) drugs got used.

Background and Aim
Achieving adequate motor and sensory blockage in spinal anesthesia allows the comfortable performance of surgical interventions. However, in certain operations on the lower extremities, surgeons report that adequate muscle relaxation is not achieved. The purpose of this study was to evaluate muscle relaxation subsequent to the administration of spinal anesthesia in orthopedic cases of the lower extremities, using muscle monitoring (Train-of-four) (TOF) and comparing these values with motor and sensory block levels.
Methods
Ninety-four patients were divided into 3 groups after spinal anesthesia according to maximum sensory block levels. Group I: T10 (n=30), Group II: T8 (n=35), Group III: T6 (n=29). The patients’ sensory, motor blocks and TOF values were recorded at the 5th, 10th, 20th, and 30th minutes.
Results
Significant differences were seen between groups (p<0.001) in terms of TOF values at the 5th, 10th, 20th, and 30th minutes. In Group III, with the highest sensory block level, the Bromage score was 3 in 28 of the 29 patients at the 30th minute, and the median TOF value was found to be 83.
Conclusion
It was seen in our study that as sensory and motor block levels increased with the level of spinal anesthesia, the TOF ratios that show muscle relaxation fell. However, the TOF values were still found to be above the 70% level indicating effective muscle relaxation. It may therefore be said that during spinal anesthesia, although maximum motor and sensory blockage is achieved, full muscle relaxation cannot always be ensured.

Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied presentations. However, clinical malaria or scrub typhus is unusual without fever. On the other hand, altered sensorium with or without fever, dehydration, hemorrhage and hemolysis may lead to low blood pressure. Presence of toxic granules and elevated band forms in such patients can even mimic sepsis. When such a patient is in the peripartum period, it creates a strong clinical dilemma for the physician especially in unbooked obstetric cases. We present such a case where a 26-year-old unbooked female presented on second postpartum day with severe anemia, altered sensorium, difficulty in breathing along with jaundice and gum bleeding without history of fever. Rapid diagnostic test for malaria was negative and no eschar was seen. These parameters suggested a diagnosis of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet) syndrome with or without puerperal sepsis. Subsequently she was diagnosed as having asymptomatic malaria and scrub typhus and responded to the treatment of it. The biochemical changes suggestive of HELLP syndrome also subsided. We present this case to emphasize the fact that mere absence of fever and eschar does not rule out scrub typhus. It should also be considered as a differential diagnosis in patients with symptoms and signs suggesting HELLP syndrome. Asymptomatic malaria can complicate case scenario towards puerperal sepsis by giving false toxic granules and band form in such situations.

Objective. - The regional anesthesia (LRA) has great benefits in the management of emergency patients. A regional investigation was conducted to estimate the practice of LRA by emergency physicians.
Patients and method. - This multicenter and descriptive survey was conducted from January 1 to April 30, 2012 in the 46 emergency departments of a French county. One hundred forty-four emergency physicians completed a questionnaire about their training and daily LRA's practice.
Results. - The rate of participation reached 45 % and 71 % of doctors practiced LRA. Indications were: pain relief (71 %), exploration (60 %) or reduction of fracture (52 %). There was a statistical association between the experiment of the doctor and the practice of the LRA (p = 0.01). 72 % of physicians judged the usefulness of LRA. However, the practitioners underlined a lack of training (46 %), rare indications (30 %), a fear (6 %) and a lack of interest (3 %). The nerve block realized were: the femoral block (60 %), the hand block (21%), the face block (13 %) and the footblock (2 %). Physicians were 65 % didn’t' know the recommendations and 69 % were unaware of lipid emulsions used for treatment of local anesthetic systemic toxicity. 97 % of practitioners are interested in a regional training.
Conclusion. - Ten years after the recommendations, it turns out that there is a lack of knowledge and a real need for training of emergency physicians in the studied county.
Introduction. - Les techniques d’anesthésie loco-régionales (ALR) sont des grands bénéfices dans la prise en charge des patients en urgence. But du travail : évaluer la pratique régionale de ALR par les médecins exerçant dans les services d’urgences-Samu-Smur.
Patients et méthode. - Enquête multicentrique, observationnelle, descriptive menée du 1er janvier au 30 avril 2012 auprès des 46 structures d’une région de France. Cent quarante-quatre médecins urgentistes ont complété un questionnaire concernant leur formation et leur pratique quotidienne en ALR.
Résultats. - Le taux de participation s’élevait à 45 % et 71 % des répondeurs (n = 102) pratiquaient l’ALR. Les indications retenues étaient : l’analgésie (71 %), l’exploration de plaies (60 %), la réduction de fracture ou luxation (52 %). La pratique de l’ALR était liée à l’expérience du médecin (p = 0,01).. Les médecins étaient 72% à juger l’ALR utile et soulignaient un manque de formation (46%), des indications rares (30%), une crainte (6 %) et un manque d’intérêt (3 %). Les ALR réalisées étaient : le bloc fémoral (60 %), de la main au poignet (21 %), de la face (13 %) et du pied (2 %). Si 65 % ne connaissaient pas les recommandations, 69 % ignoraient l’existence des émulsions lipidiques pour traiter les intoxications aux anesthésiques locaux. 97 % seraient intéressés par une formation régionale.
Conclusion. - Dix ans après les recommandations, au sein de la région française étudiée, il existait une méconnaissance de ces techniques, alors que les urgentistes exprimaient un souhait réel de formation.

Anesthetic consideration of obstetric patients with pituitary disorders is an important topic to deal with. Few cases were reported with accidently discovered pituitary tumor complications especially in the postpartum period. A 26 years old primigravida lady with 39 weeks gestational period was reported to have severe headache and sudden loss of conscious after normal vaginal delivery with lumbar epidural anesthesia. Accidently discovered pituitary adenoma was proved after neurology, endocrine and ophthalmology consultations. Hence, undiagnosed pituitary adenomas should be taken in to consideration with unexplained postpartum generalized weakness and loss of conscious especially after exclusion of epidural anesthesia complications.

Rationale
The mechanical ventilation may aggravate the severe acute lung injury and trigger a systemic inflammatory response. The pathophysiology evolves
Biotrauma, meaning that the over distension and the cyclical opening/collapse of structures on the lung during ventilation with high PIP associated
with low PEEP, results in excessive activation of nuclear factor-{kappa}Beta (NF-κB), a regulator of the inflammatory response, that exacerbates the
local response and becomes it systemic. The magnesium, a modulator of signaling pathways of the inflammatory cascade, deserves investigation in
inhibiting the NF-κB activation.
Objectives
Investigate experimentally the effect of hypermagnesemia to inhibit the activation and migration of NF-κB from cytoplasm to nucleus in cells of lungs
injured by mechanical ventilation.
Methods
Two experimental groups of 15 Sprague-Dawley rats each, one receiving 1.25 mL/kg/h of a 10% MgSO4 solution, other receiving equal volume of
saline, both under mechanical ventilation with VT of 40 mL/kg, PEEP of 3 cmH2O, PIP of 35 cm H2O, RR of 40 cycles per minute. Lungs were excised
after 50 minutes of experimental interventions and prepared for further immunohistochemical analysis.
Measurements and Main Results
ANOVA shown no differences when compared the NF-κB activation values in the cytoplasm (712.44 ± 253.86) and nucleus (974.27 ± 344.59) of cells
in MgSO4 group with the respective values in cytoplasm (653.99 ± 272.98) and nucleus (952.29 ± 346.68) of cells in Saline group (F[1, 28] = 0.90, p >
.05).
Conclusions
There was no inhibitory effect of magnesium on the activation of NF-kB nor on its expression through migration to the nucleus.

Background
The effects of stellate ganglion block (SGB) on radicular pain associated with cervical spondylosis remain to be clarified. So we measured salivary alpha-amylase which reflects sympathetic nerve activity under psychological stress after SGB block or trigger points injection (TPI).
Study Design
A randomized, prospective, controlled trial
Setting
After institutional approval and informed consent, 40 patients who was suffered from neck-shoulder pain associated with cervical radiculopathy were randomly divided into two groups according to nerve block treatment. Group A (n=20, male 10 patients, female 10 patients, 50±8yr, mean±SD) received SGB and group B (n=20, male 10 patients, female 10 patients, 52±6yr) received TPI. SGB or TPI was produced by 6 ml of 1% mepivacaine a total of 5 times (twice per week). Visual analogue scale (VAS) and the concentration of salivary alpha-amylase were measured before (T0) each nerve block and 3 days (T1), 6 days (T2), 9 days (T3), 12 days (T4) and 15days (T5) after each nerve block. The consumption of non-steroidal anti-inflammatory drug (NSAID) was measured at T0 and T5 in each group.
Results
In group A, VAS was median 74 (range 60, 78) at T0 and showed a significant decrease at T3 [53 (48, 65), p<0.05], T4 [50 (42, 66), p<0.05] and T5 [48 (26,57), p<0.05]. The concentration of salivary alpha-amylase was median 116 (range 96, 144) KU/ml at T0 and showed a significant decrease at T3 [86 (79, 105), p<0.05], T4 [79 (68, 88)] and T5 [70 (55, 84), p<0.05]. In group B, VAS and the concentration of salivary alpha-amylase showed no change throughout the time course. VAS in group A was significant lower than that in group B at T3, T4 and T5. The concentration of salivary alpha-amylase was significant lower than that in group B at T4 and T5. The consumption of NSAID in group A was significantly lower than that in group B at T5.
Limitations
Subjects are out patients. Patients include radicular pain due to different pathogenesis, e.g., cervical herniated intervertebral disc, disc bulging, and neuro-foramen narrowing.
Conclusion
The results indicate that SGB shows the reduction of VAS scale and the concentration of salivary alpha-amylase in patients with cervical spondylosis. These results show that salivary alpha-amylase activity could reflect the physical stress with radicular pain.